{"id":2736,"title":"Health Unlimited: Proposal Form","purpose":"proposal","insurer":{"slug":"generali-central-insurance","name":"Generali Central Insurance Company Limited"},"source_pdf":"https://www.generalicentralinsurance.com/downloads/health-insurance/health-unlimited/proposal-forms/health-unlimited-proposal-form.pdf.pdf","sha256":"f72f9db36a80a94a8ad33ec25a2dee97bdf1b4e00aff67b6bbeb53b04132a3ec","pages":9,"collected":"2026-10-17","instructions":{"about":"This form is a health insurance proposal form to be filled by the proposer seeking insurance coverage under the Health Unlimited plan offered by Generali Central Insurance Company Limited.","notes":["Fill all sections in capital letters and check applicable boxes.","Fields marked with * are mandatory.","Use original documents for age proof.","Attach portability/migration form if applying for portability.","E-mandate/E-NACH activation is required for instalment payments.","Policy document will be sent digitally unless physical copy is requested.","Use block letters and provide accurate contact details.","Premium payment must be from legal sources as per AML regulations.","Keep a copy of the filled form and submitted documents for reference."],"title":"Health Unlimited: Proposal Form","submit":{"to":"Generali Central Insurance Company Limited","how":"","address":"Registered Office: Unit No. 801 & 802, 8th Floor, Tower C, Embassy 247 Park, LBS Marg, Vikhroli (West), Mumbai – 400083; Email ID: gcicare@generalicentral.com"},"purpose":"proposal","sections":[{"title":"I. PROPOSER DETAILS","fields":[{"help":"Select appropriate title and enter full name in capital letters","type":"text","label":"Proposer Name*","options":["Mr.","Mrs.","Ms.","M/s"],"required":true,"pdf_field":""},{"help":"Enter date of birth in DD/MM/YYYY format","type":"date","label":"Date of Birth*","options":[],"required":true,"pdf_field":""},{"help":"Enter age in years","type":"number","label":"Age (in years)","options":[],"required":false,"pdf_field":""},{"help":"Select one","type":"choice","label":"Marital Status*","options":["Married","Single","Widow / Widower","Divorcee","In Live-in relation"],"required":true,"pdf_field":""},{"help":"Select one and specify if Others","type":"choice","label":"Nationality*","options":["Indian","NRI","Others (please specify)"],"required":true,"pdf_field":""},{"help":"Select one","type":"choice","label":"Gender*","options":["Male","Female","Third Gender"],"required":true,"pdf_field":""},{"help":"Enter valid email address","type":"email","label":"E-mail ID*","options":[],"required":true,"pdf_field":""},{"help":"Select one and specify if Others","type":"choice","label":"Occupation*","options":["Self Employed","Salaried","Homemaker","Retired","Others (please specify)"],"required":true,"pdf_field":""},{"help":"Mandatory if premium exceeds Rs. 50,000 in cash or Rs. 1,00,000 in any mode","type":"text","label":"PAN","options":[],"required":false,"pdf_field":""},{"help":"Enter full permanent address","type":"text","label":"Permanent Address","options":[],"required":false,"pdf_field":""},{"help":"Enter landmark near permanent address","type":"text","label":"Landmark","options":[],"required":false,"pdf_field":""},{"help":"Enter city or town of permanent address","type":"text","label":"City / Town","options":[],"required":false,"pdf_field":""},{"help":"Enter district of permanent address","type":"text","label":"District","options":[],"required":false,"pdf_field":""},{"help":"Enter pin code of permanent address","type":"number","label":"Pin Code*","options":[],"required":true,"pdf_field":""},{"help":"Enter telephone number","type":"phone","label":"Telephone No.*","options":[],"required":true,"pdf_field":""},{"help":"Enter mobile number","type":"phone","label":"Mobile No.*","options":[],"required":true,"pdf_field":""},{"help":"Enter present address or tick if same as permanent","type":"text","label":"Present Address (If same as above, please tick here)","options":[],"required":false,"pdf_field":""},{"help":"Enter landmark near present address","type":"text","label":"Landmark","options":[],"required":false,"pdf_field":""},{"help":"Enter city or town of present address","type":"text","label":"City / Town","options":[],"required":false,"pdf_field":""},{"help":"Enter district of present address","type":"text","label":"District","options":[],"required":false,"pdf_field":""},{"help":"Enter pin code of present address","type":"number","label":"Pin Code*","options":[],"required":true,"pdf_field":""},{"help":"Enter telephone number","type":"phone","label":"Telephone No.*","options":[],"required":true,"pdf_field":""},{"help":"Enter mobile number","type":"phone","label":"Mobile No.*","options":[],"required":true,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Are you an existing GCICL policyholder? *","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Enter existing policy number if applicable","type":"text","label":"If Yes, Please Provide Existing Policy No.","options":[],"required":false,"pdf_field":""},{"help":"Enter customer number if applicable","type":"text","label":"Customer No.","options":[],"required":false,"pdf_field":""},{"help":"Tick if applicable","type":"checkbox","label":"If you are Differently Abled, please tick mark on the checkbox to provide confirmation?","options":[],"required":false,"pdf_field":""},{"help":"Specify type of impairment","type":"text","label":"Type of Impairment","options":[],"required":false,"pdf_field":""},{"help":"Enter percentage of impairment","type":"number","label":"Percentage of Impairment","options":[],"required":false,"pdf_field":""},{"help":"Enter UDID number","type":"text","label":"UDID Number","options":[],"required":false,"pdf_field":""},{"help":"Enter IO or Win number","type":"text","label":"IO No/Win No.","options":[],"required":false,"pdf_field":""},{"help":"Enter application number","type":"text","label":"App No","options":[],"required":false,"pdf_field":""},{"help":"Enter client code if available","type":"text","label":"HEALTH UNLIMITED Client Code","options":[],"required":false,"pdf_field":""},{"help":"Enter receipt number if available","type":"text","label":"Receipt No","options":[],"required":false,"pdf_field":""},{"help":"Enter payer ID if available","type":"text","label":"Payer ID","options":[],"required":false,"pdf_field":""},{"help":"Enter bank account number if available","type":"text","label":"SB / CA Account No","options":[],"required":false,"pdf_field":""},{"help":"Enter journal number or bank name if available","type":"text","label":"Journal No / Bank Name","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"II. PLAN DETAILS","fields":[{"help":"Select policy period","type":"choice","label":"Policy Period *","options":["1 Year","2 Years","3 Years"],"required":true,"pdf_field":""},{"help":"Enter start date of policy","type":"date","label":"Proposed Policy Period* From","options":[],"required":true,"pdf_field":""},{"help":"Select cover type","type":"choice","label":"Cover Type*","options":["Individual","Family Floater"],"required":true,"pdf_field":""},{"help":"Tick if opting for Zone 1","type":"checkbox","label":"For Proposer/Policyholder of Zone 2 – If you want to opt for Zone 1, please tick mark to provide confirmation","options":[],"required":false,"pdf_field":""},{"help":"Select sum insured","type":"choice","label":"Sum Insured","options":["₹ 7,50,000","₹ 10,00,000","₹ 15,00,000","₹ 25,00,000","₹ 50,00,000","₹ 1,00,00,000","₹ 2,00,00,000"],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Consumables / Non-Medical Expenses Cover","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Waiver of Mandatory Co-Payment (for Insured member aged 61 years and above)","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"III. DETAILS OF PROPOSED INSURED PERSONS*","fields":[{"help":"Fill details for each insured person: Sr. No., Name, Gender, Date of Birth (DD/MM/YYYY), Relationship with Proposer, ABHA No., Height (Cm), Weight (Kg), Occupation, Only for Individual Cover Type, Sum Insured (Rs.), Deductible (Rs.)","type":"table","label":"Details of Proposed Insured Persons","options":[],"required":true,"pdf_field":""},{"help":"Attach Passport, PAN card, driving license, school/college leaving certificate, or letter from recognized public authority","type":"attachment","label":"Please attach age proof document for each person proposed to be insured","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"IV. NOMINEE DETAILS","fields":[{"help":"Provide Name, Age, Mobile No., Email ID, Present Address, Permanent Address (tick if same), Relationship with Proposer, Percentage (%) of Claim amount payable, Bank details (Account No., IFSC/MICR Code, Bank Name, Account Holder Name) for up to 4 nominees","type":"table","label":"Nominee Details","options":[],"required":false,"pdf_field":""},{"help":"Provide Name, Age, Mobile No., Email ID, Present Address, Permanent Address (tick if same), Relationship with Appointee, Percentage (%) of Claim amount payable, Bank details (Account No., IFSC/MICR Code, Bank Name, Account Holder Name) for up to 4 appointees","type":"table","label":"Appointee Details (Required only if the nominee is a minor)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"VII. CONCURRENT/PREVIOUS INSURANCE POLICY DETAILS","fields":[{"help":"Select Yes or No","type":"yes-no","label":"Are you applying for portability / migration?","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"VIII. PREMIUM PAYMENT AND BANK DETAILS*","fields":[{"help":"Select instalment frequency if opting for instalments","type":"choice","label":"Instalment Frequency","options":["Monthly","Quarterly","Half Yearly","Annually"],"required":false,"pdf_field":""},{"help":"Tick to opt for E-mandate/E-NACH and provide Bank Name","type":"checkbox","label":"E-mandate/E-NACH*","options":[],"required":false,"pdf_field":""},{"help":"Select payment option and specify if Others","type":"choice","label":"Payment Option","options":["Cheque","Demand Draft","Fund Transfer","Pay Order","Debit Card","Credit Card","Others (please specify)"],"required":false,"pdf_field":""},{"help":"Enter premium amount in rupees","type":"amount","label":"Premium Amount","options":[],"required":true,"pdf_field":""},{"help":"Write premium amount in words","type":"text","label":"Amount in Words","options":[],"required":true,"pdf_field":""},{"help":"Enter account holder name for payment","type":"text","label":"Account Holder Name","options":[],"required":false,"pdf_field":""},{"help":"Enter cheque/DD/instrument number","type":"text","label":"Instrument Number","options":[],"required":false,"pdf_field":""},{"help":"Enter instrument date","type":"date","label":"Instrument Date","options":[],"required":false,"pdf_field":""},{"help":"Enter transaction ID for online payments","type":"text","label":"Transaction ID (for online payments)","options":[],"required":false,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Bank Name","options":[],"required":false,"pdf_field":""},{"help":"Select account type","type":"choice","label":"Account Type","options":["Savings","Current","Others (please specify)"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"IX. ELECTRONIC INSURANCE ACCOUNT DETAILS OF PROPOSER","fields":[{"help":"Select Yes or No","type":"yes-no","label":"Do you have an eIA","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"If No, do you wish to apply for eIA","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter EIA number if available","type":"text","label":"If yes, please quote the EIA number","options":[],"required":false,"pdf_field":""},{"help":"Enter preferred insurance repository","type":"text","label":"If applied, please mention your preferred Insurance Repository","options":[],"required":false,"pdf_field":""},{"help":"Enter registered email ID","type":"email","label":"Email Id (Registered with Insurance Repository)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"XI. DECLARATION","fields":[{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Enter full name","type":"text","label":"Proposer Name","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"XII. INTERMEDIARY AND AUTHORIZED REPRESENTATIVE DECLARATIONS","fields":[{"help":"Agent/Intermediary to sign and provide name, code, PAN","type":"signature","label":"Intermediary Declaration","options":[],"required":true,"pdf_field":""},{"help":"Witness to sign and provide name, date, place","type":"signature","label":"Vernacular Declaration","options":[],"required":false,"pdf_field":""},{"help":"Authorized representative to sign and provide details and witness signature","type":"signature","label":"Declaration by Authorized Representative or Person with Disability","options":[],"required":false,"pdf_field":""}],"filled_by":"intermediary / authorized representative"}],"deadlines":[],"applies_to":"Health Unlimited insurance policies","attachments":["Age proof documents for each person proposed to be insured (Passport, PAN card, driving license, school/college leaving certificate, Letter from recognized public authority)","Portability / migration form (if applying for portability)","Request for authorisation form to receive Claim / Refund Payments through NEFT (mandatory if premium > ₹ 10,000)"],"declarations":["The proposer declares all information is true and complete to the best of their knowledge.","The policy will come into force only after full payment of premium.","The proposer will notify any change in occupation or health before risk acceptance.","The company may seek medical and other information for underwriting and claims.","The company may share proposal and medical information with government and regulatory authorities.","Non-disclosure or untrue information may void the policy and forfeit premium.","The proposer consents to receive service-related information electronically.","The information provided will be stored and used for insurance and servicing purposes.","The premium is paid from legally declared sources and not from proceeds of crime.","The proposer confirms who paid the premium and authorizes refund to proposer’s bank account.","The proposer declares if they belong to any special categories like HNI, NRI, Politically Exposed Person, etc.","The proposer consents to processing of personal data as per insurer’s privacy policy.","If ABHA number is shared, consent is given to use it for accessing medical history confidentially.","The proposer consents to CKYC record verification and receiving related communications.","Consent is given for Bima-ASBA facility to block premium amount in bank account upon proposal acceptance."],"dropped_labels":8},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"grievance","channel":"email","value":"GCIcare@generalicentral.com","label":"HELPLINE Email","level":1,"hours":null,"applies_to":"all","source_url":"https://www.generalicentralinsurance.com/customer-service/grievance-redressal","quote":"atrix given below.\nLEVEL 1\nYou Can Call On Our HELPLINE\n1800-220-233 / 1860-500-3333 / 022-67837800\nOR\nSEND US AN EMAIL\nGCIcare@generalicentral.com\nOur senior citizen policyholders can avail priority support by choosing the valid option from the helpline menu or writ","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"1800-220-233 / 1860-500-3333 / 022-67837800","label":"HELPLINE","level":1,"hours":null,"applies_to":"all","source_url":"https://www.generalicentralinsurance.com/customer-service/grievance-redressal","quote":"may have. You can escalate your concerns as per the\nescalation matrix given below.\nLEVEL 1\nYou Can Call On Our HELPLINE\n1800-220-233 / 1860-500-3333 / 022-67837800\nOR\nSEND US AN EMAIL\nGCIcare@generalicentral.com\nOur senior citizen policyholders can avail priority support by choosing","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"address","value":"Generali Central Insurance Company Ltd.\nUnit No. 301, 3rd Floor Part, Building No. 8,\nMindspace IT/ITES SEZ, MIDC Industrial Area,\nAiravali, Navi Mumbai,\nThane District – 400 708.","label":"Corporate Grievance Redressal Officer (GRO) Address","level":2,"hours":null,"applies_to":"all","source_url":"https://www.generalicentralinsurance.com/customer-service/grievance-redressal","quote":"ON\n+91-79001 97777\nOR\nSend your complaint to our Corporate Grievance Redressal Officer\nMr. Hari Shankar Mishra\nADDRESS\nGenerali Central Insurance Company Ltd.\nUnit No. 301, 3\nrd\nFloor Part, Building No. 8,\nMindspace IT/ITES SEZ, MIDC Industrial Area,\nAiravali, Navi Mumbai,\nThane District – 400 708.\nLEVEL 3\nIf you are still not satisfied with the solution provided, you can email\nour CEO’s office.\nEMAIL OUR CEO’s OFF","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"GCIGRO@generalicentral.com","label":"Corporate Grievance Redressal Officer (GRO) Email","level":2,"hours":null,"applies_to":"all","source_url":"https://www.generalicentralinsurance.com/customer-service/grievance-redressal","quote":"solution provided to you does not meet your expectations,\nyou can write directly to our Corporate GRO.\nSEND US AN EMAIL\nGCIGRO@generalicentral.com\nOR\nCALL US ON\n+91-79001 97777\nOR\nSend your complaint to our Corporate Grievance Redressal Officer\nMr. Hari Shankar Mish","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"+91-79001 97777","label":"Corporate Grievance Redressal Officer (GRO) Phone","level":2,"hours":null,"applies_to":"all","source_url":"https://www.generalicentralinsurance.com/customer-service/grievance-redressal","quote":"ur expectations,\nyou can write directly to our Corporate GRO.\nSEND US AN EMAIL\nGCIGRO@generalicentral.com\nOR\nCALL US ON\n+91-79001 97777\nOR\nSend your complaint to our Corporate Grievance Redressal Officer\nMr. Hari Shankar Mishra\nADDRESS\nGenerali Central In","fetched_at":"2026-10-20"}],"how_to_use":"Ask the user for each field in order, in plain words; never invent an answer. Labels are as printed. If fillable_pdf is true, pdf_fields gives the PDF's own field names so the file can be filled directly. The printed form decides if anything differs.","url":"https://indiainsurances.com/forms/generali-central-insurance/2736-health-unlimited-proposal-form"}